Healthcare Provider Details

I. General information

NPI: 1790175917
Provider Name (Legal Business Name): INNER COASTAL ORTHOTICS AND PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 NORTH BROWN ST.
WASHINGTON NC
27889
US

IV. Provider business mailing address

1102 NORTH BROWN ST.
WASHINGTON NC
27889
US

V. Phone/Fax

Practice location:
  • Phone: 252-623-2200
  • Fax: 252-623-2015
Mailing address:
  • Phone: 252-623-2200
  • Fax: 252-623-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name: GREG MICHAEL BERRY
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 252-623-2200